|LETTERS TO EDITOR
|Year : 2021 | Volume
| Issue : 1 | Page : 161-163
Cytologic abnormalities noted in the cervical smears of high-risk persons
SP Somashekhar1, Geetu Bhandoria2, Vijay Ahuja1
1 Manipal Comprehensive Cancer Center, Manipal Hospitals, Bengaluru, Karnataka, India
2 Department of Gyn-Oncology and Obstetrics, Command Hospital, Kolkata, West Bengal, India
|Date of Submission||24-Feb-2021|
|Date of Decision||28-Feb-2021|
|Date of Acceptance||01-Mar-2021|
|Date of Web Publication||26-Mar-2021|
S P Somashekhar
Manipal Comprehensive Cancer Center, Manipal Hospital, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Somashekhar S P, Bhandoria G, Ahuja V. Cytologic abnormalities noted in the cervical smears of high-risk persons. Cancer Res Stat Treat 2021;4:161-3
|How to cite this URL:|
Somashekhar S P, Bhandoria G, Ahuja V. Cytologic abnormalities noted in the cervical smears of high-risk persons. Cancer Res Stat Treat [serial online] 2021 [cited 2021 Apr 23];4:161-3. Available from: https://www.crstonline.com/text.asp?2021/4/1/161/312107
Cervical cancer is the second most common cancer in women in India and results in significant morbidity and mortality. In the developed countries, the early implementation of cytology-based screening programs has led to a drastic reduction in the incidence of cervical cancer. With the recent advancements in human papillomavirus (HPV)-based screening and the use of the HPV vaccine, the incidence of cervical cancer is likely to reduce further. However in India, although the incidence of cervical cancer has slightly decreased, greater efforts are required to achieve an effective reduction in the incidence and mortality of this disease., In line with this, the World Health Organization (WHO) has formulated a strategy for the elimination of cervical cancer and set goals related to vaccination, screening, and treatment to be met by 2030. With limited resources for universal screening in a developing country like ours, an initial focus on the high-risk populations may be worthwhile. In this context, Sahadevan Kanthimathy et al. have attempted to define the prevalence of cytological abnormalities in a selected high-risk population, based on the sexual behavior. The authors have claimed that theirs is the first study from Kerala that specifically targets the community of female sexual workers in a rural setting. However, a similar study was conducted in 2016 in Chandigarh, India, by Singh et al.
Sahadevan Kanthimathy et al. used the conventional Pap smear for the detection of cytological abnormalities; and a subset of the study population (116/277) was also tested by liquid-based cytology (LBC). Thus, all the patients underwent either a conventional Pap, LBC, or high-risk HPV DNA testing. The detection of an inflammatory smear was comparable in both the studies (over 50%). Smears from 12 women were unsatisfactory and excluded from the study. This could have been averted by incorporating LBC for all the patients in the study.
It would be useful to discuss the utility of visual inspection with acetic acid-based screening, as recommended by the WHO, for resource-constrained countries. This screening method would be more applicable in the rural setup, as discussed in several recent publications., In addition, it could add more value to the current screening practices which vary in different regions of India.
Although Sahadevan Kanthimathy et al. in their study have analyzed various relevant risk factors, certain aspects of the study methodology and interpretations are open to debate. First, the smears were collected by trained cytotechnologists instead of a trained physician or nurse/midwife which is contrary to the usual practice. A comparative analysis of the age groups showed that women belonging to the younger age groups had a significantly greater number of epithelial abnormalities than those belonging to the older age groups. This finding appears to be inaccurate as absolute numbers were considered for comparison instead of the relative proportion of cases in each age group.
The protocol described for the management of abnormal smear results is also subject to scrutiny and contrary to the established guidelines. For the management of the atypical squamous cells of undetermined significance (ASCUS) and low-grade squamous intraepithelial lesions (LSILs), the authors suggested a repeat smear after 6 months, and in the case of persistent abnormalities, a loop electrosurgical excision procedure (LEEP) was recommended. Contrary to this, the established guidelines clearly recommend a colposcopy and guided biopsy followed by appropriate treatment based on the histology. Similarly, hysterectomy has been incorrectly recommended as a treatment for ASC-H and LSILs high grade squamous intraepithelial lesions instead of specifying the indications for LEEP and hysterectomy based on the final histology of the colposcopic biopsy.
The authors have drawn the conclusion that all cytological abnormalities described in the study are precancerous. However, it should have been clarified that a diagnosis of precancerous lesions is based on the histology of the biopsy showing cervical intraepithelial neoplasia II/III. In addition, the protocols for colposcopy and biopsy were not defined, and the number of biopsies done was small. As the sensitivity of a single pap smear is limited, a colposcopic evaluation of cases with persistent ASC-US and LSIL is important; otherwise, some cases that are likely to have precancerous lesions will be missed. To assess the impact of high-risk behavior on the incidence of precancerous lesions, a comparison with an average-risk population is necessary. Therefore, a comparison of the high-risk population with a matched average-risk population could have added value to this study.
The current screening guidelines do not differentiate between women at average risk and those with high-risk sexual behaviors. The preferred modality described is co-testing with cytology and HPV testing.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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